Healthcare Provider Details

I. General information

NPI: 1407327273
Provider Name (Legal Business Name): ZACHARY T KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N WASHINGTON ST
SUMTER SC
29150-4949
US

IV. Provider business mailing address

1925 ADIRONDACK CT
SUMTER SC
29153-8313
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-9000
  • Fax:
Mailing address:
  • Phone: 803-420-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number225946
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: